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Dixie Eastridge Clinical Director/Behavior Analyst
Learning Services Neurobehavioral Ins>tute-‐West Lakewood, Colorado
Return on Investment Medications in Patient
Services
Behavior • The ability to respond, use previously acquired skill sets, and to learn new skills may be impacted
• Do not assume that a person can perform a skill because they did so in the past
• A person with a brain injury oJen shows poor insight and judgment
Antecedents • Typical stimuli conditions may affect behavior and function
as aversive stimuli • Responses to the perceived aversive situation may include
attempts to escape and avoid the unpleasant stimuli or situations. – There may be an over sensitivity to sounds, lights, aromas, tastes,
and touch. This may affect the way stimuli affect behavior 1. Impacting accuracy in executing responses 2. Timing and precision based on cues 3. Reducing generalization of behavior 4. Application of skills to new situations 5. Reducing contextual control 6. How situations are interpreted
• Reduce intensity of sounds, lights, temperature • Be aware of your nonverbal communica>on, facial expressions and tone of voice
• Model calmness and confidence • Use structure and consistency to ensure events are more predictable
• Provide concise instruc>ons and offer choices – Avoid using ques>ons. i.e. Are you ready to get your shower?
– State as choice-‐ Do you want to use a wash cloth or a puff for your shower?
Antecedent Interven>ons
Consequences
• Changes in brain activity resulting from a brain injury and the disruption of previous learned behavior - reinforcer relationships may cause behavior to become unstable, agitated, and unpredictable
• Treatment approaches are aimed at reducing agitated depression, anxiety, personality changes and environmental changes
Consequence Interven>ons • Reinforce quick responses to requests • Performance and mee>ng goals • Use posi>ve statements at a 4:1 ra>o • Factors affec>ng the effect of reinforcers
• Magnitude, • Dura>on, • Frequency • Delay • Schedule
– Variable-‐ra)o schedules (VR): reinforcing the target behavior aJer an unpredictable number of responses. e.g., VR:10
• Rapid and steady responding.
Brain Injury and Frustra>on • Frustra>on may occur because-‐
– Physical ac>vi>es are harder to do – Daily ac>vi>es previously taken for granted are difficult or impossible to accomplish
– Lack of compensatory strategies for physical/cogni>ve deficits
– Difficulty remembering or using new ways of doing common ac>vi>es such as dressing, ea>ng, ge\ng around, handling money, etc.
– Emo>onal reac>ons may come more easily
Brain injury and aggression Can we get some help? 1. Tony M. Wong, PhD
+SHOW AFFILIATIONS 1. From the Department of Physical Medicine and Rehabilitation, University of Rochester School of Medicine & Dentistry; and Unity Health System, Rochester, NY.
2. Address correspondence and reprint requests to Dr. Tony M. Wong, Unity Health System, 89 Genesee Street, Rochester, NY 14611 twong@unityhealth.org
3. doi: 10.1212/WNL.0b013e318211c3fd Neurology March 22, 2011 vol. 76 no. 12 1032-1033
• » Excerpt
• Full Text • Full Text (PDF)
For the clinician who has had any depth of experience working with a brain-injured population, there is little doubt that behavioral problems following traumatic brain injury (TBI) can present significant management challenges. Common in TBI, behavioral disinhibition and associated problems may increase over the first year following injury,
1 and are often associated with damage to the prefrontal regions of the brain.
2–4 Estimates of the occurrence of agitation or aggression range from 35% to 96% of patients with TBI during the acute period and from 31% to 71% of these patients in the chronic phase.
5
Brain injury and aggression Can we get some help? 1. Tony M. Wong, PhD
+SHOW AFFILIATIONS 1. From the Department of Physical Medicine and Rehabilitation, University of Rochester School of Medicine & Dentistry; and Unity Health System, Rochester, NY.
2. Address correspondence and reprint requests to Dr. Tony M. Wong, Unity Health System, 89 Genesee Street, Rochester, NY 14611 twong@unityhealth.org
3. doi: 10.1212/WNL.0b013e318211c3fd Neurology March 22, 2011 vol. 76 no. 12 1032-1033
• » Excerpt
• Full Text • Full Text (PDF)
For the clinician who has had any depth of experience working with a brain-injured population, there is little doubt that behavioral problems following traumatic brain injury (TBI) can present significant management challenges. Common in TBI, behavioral disinhibition and associated problems may increase over the first year following injury,
1 and are often associated with damage to the prefrontal regions of the brain.
2–4 Estimates of the occurrence of agitation or aggression range from 35% to 96% of patients with TBI during the acute period and from 31% to 71% of these patients in the chronic phase.
5
Brain injury and aggression Can we get some hel
p? 1.Tony M. Wong, PhD +SHOW AFFILIATIONS 1.From the Department of Physical Medicine and Rehabilitation, University of Rochester School of Medicine & Dentistry; and Unity Health System, Rochester, NY. 2.Address correspondence and reprint requests to Dr. Tony M. Wong,
Unity Health System, 89 Genesee Street, Rochester, NY 14611 twong@unityhealth.org 3.doi: 10.1212/WNL.0b013e318211c3fd Neurology
March 22, 2011 vol. 76 no. 12 1032-1033 •» Excerpt •Full Text •Full Text (PDF) For the clinician who has had any depth of experience working with a brain-injured population, there is little doubt that behavioral problems following traumatic brain injury (TBI) can present significant management challenges. Common in TBI, behavioral disinhibition and associated problems may increase over the first year following injury,1 and are often associated with damage to the prefrontal regions of the brain.2–4 Estimates of the occurrence of agitation or aggression range from 35% to 96% of patients with TBI during the acute period and from 31% to 71% of these patients in the chronic phase.5
Estimates of the occurrence of agitation or aggression range from 35% to 96% of patients with TBI during the acute period and from 31% to 71% of these patients in the chronic phase.5
Agitation occurs commonly in the delirious subacute phase of recovery. Chronic irritability and aggression are seen in ~40 to 70% of patients with TBI. Aggression in patients with TBI is generally reactive without premeditation, and is nonpurposeful, explosive, periodic, and egodystonic
Agita>on and Aggression
A Bit of Frustra>on • People need to struggle
– Difficult tasks are necessary to learn how
to do them and to learn how to handle frustra>on – Too much help can prevent this process – Brain imaging experts with Baycrest’s Rotman Research Ins>tute in Toronto found a dis>nct “brain signature” in pa>ents who have recovered from head injuries that shows their brains may have to work harder than the brains of healthy people to perform at the same level.
But….Not TOO Much Frustra>on
• The best help will allow the person to calm down enough to work through how to do the task, rather than have the task done for them
• Too much help can lead to learned helplessness
Management of Frustra>on • Increase rest >me
– People with TBI may fa>gue easily, which may contribute to behavioral issues
• Keep the environment simple – People with a brain injury may be easily over-‐ s>mulated by the surroundings
• Keep instruc>ons simple – Instruc>ons, prompts, and cues should be kept as concrete and simple as possible
Management of Frustra>on • Give feedback and set goals
– Due to diminished self-‐monitoring skills feedback is impera>ve un>l the ability is relearned. Se\ng goals gives direc>on and incen>ve
• Be calm and redirect to task – People who cannot control their own behavior need others to model calm, stable, non-‐threatening behavior
Management of Frustra>on
• Offer Choices – Can reduce serious behavior problems – Allows an element of freedom and a measure of control over the environment
• Decrease the chance of failure – Work slightly above the individual's level of ability.
• Try to keep the success rate above 80% • Vary the ac>vi>es to maintain interest and increase success.
• Errorless learning
• Damage to the limbic system, orbitofrontal cortex, leJ anteromedial frontal lobe, and anterior cingulate have been par>cularly associated with aggressive behavior.[61] Studies have found increased amounts of CSF norepinephrine[62] and decreased amounts of serotonin in violent pa>ents.[63]
• Behavior modifica>on is probably the most effec>ve treatment for
these pa>ents. Careful observa>on and documenta>on of the pa>ent's aggressive outbursts may reveal triggers of and secondary gains from this behavior.
Causes of Anger
• Extreme Anger – Experienced by failing to get what we think we need or must have
• An emo>onal response to a frustrated demand
• Results from how people view what happens to them (Ellis, 1997; Novaco, 1975)
Task analysis
• Break tasks down into smaller steps – For example
• pu\ng on clothing can be broken down into several, smaller and more manageable steps that may be easier to prompt through
• Reinforce quick responses to requests • Performance and meeting goals • Use positive statements at a 4:1 ratio • Factors affecting the effect of reinforcers • Magnitude, • Duration, • Frequency • Delay • Schedule • Variable-ratio schedules (VR): reinforcing the target behavior
after an unpredictable number of responses. e.g., VR:10 • Rapid and steady responding.
Reinforcement Interventions
Drug Trend Defini>on
The annual increase in pharmacy spending-‐
the combined effect of changing drug
prices and u6liza6on
From Kupfer, Eastridge, Buzan, & Castro, 2012
SUMMARY OF MEDICATIONS
From Kupfer, Eastridge, Buzan, & Castro, 2012
0
2
4
6
8
10
12
14
8/3/
2010
8/17
/201
0
8/31
/201
0
9/14
/201
0
9/28
/201
0
10/1
2/20
10
10/2
6/20
10
11/9
/201
0
11/2
3/20
10
12/7
/201
0
12/2
1/20
10
1/4/
2011
1/18
/201
1
2/1/
2011
2/15
/201
1
3/1/
2011
Freq
uenc
y of
30
min
ute
Inte
rval
s
Date
Resident 4 Verbal/Physical Aggression
Verbal Aggression Physical Aggression
8/21 Depakote Seroquel to HS
8/25 Depakote
9/8 Orap DC Abilify Depakote DC
9/27 Lexapro
10/7 Lexapro Valium taper 11/3
Valium
11/9 Valium DC
11/7 Abilify
12/1 Valium add Mirapax
12/8 Mirapax DC Valium
12/23 Valium
1/6 Seroquel
1/12 Seroquel
1/19 Seroquel
1/26 Seroquel
2/2 Seroquel
2/9 Seroquel
2/16 Seroquel
2/23 Seroquel
Green= Add/Increase Red= Decrease/Discharge
From Kupfer, Eastridge, Buzan, & Castro, 2012
0
50
100
150
200
250
300
8/3/
2010
8/17
/201
0
8/31
/201
0
9/14
/201
0
9/28
/201
0
10/1
2/20
10
10/2
6/20
10
11/9
/201
0
11/2
3/20
10
12/7
/201
0
12/2
1/20
10
1/4/
2011
1/18
/201
1
2/1/
2011
2/15
/201
1
3/1/
2011
Freq
uenc
y of
30
min
ute
Inte
rval
s
Date
Resident 4 Cumulative Verbal/Physical Aggression
Verbal Aggression Physical Aggression
8/25 Depakote
8/21 Depakote Seroquel HS
9/8 Depakote DC Orap
9/9 Abilify
9/27 Lexapro
10/7 Lexapro Valium
11/9 Valium DC
12/1 Valium
12/8 Mirapax
12/23 Valium
1/6 Seroquel
1/12 Seroquel
1/19 Seroquel
1/26 Seroquel
2/2 Seroquel
2/9 Seroquel
2/16 Seroquel
2/23 Seroquel
11/7 Abilify
Green= Add/Increase Red= Decrease/Discharge
From Kupfer, Eastridge, Buzan, & Castro, 2012
From Kupfer, Eastridge, Buzan, & Castro, 2012
020406080
100120140160180
4/1/
2009
4/22
/200
95/
13/2
009
6/2/
2009
6/23
/200
97/
14/2
009
8/4/
2009
8/25
/200
99/
15/2
009
10/6
/200
910
/27/
2009
11/1
7/20
0912
/8/2
009
12/2
9/20
091/
19/2
010
2/9/
2010
3/2/
2010
3/23
/201
04/
13/2
010
5/4/
2010
5/25
/201
06/
15/2
010
7/6/
2010
7/27
/201
08/
17/2
010
9/7/
2010
9/28
/201
010
/19/
2010
11/9
/201
011
/30/
2010
12/2
1/20
101/
11/2
011
2/1/
2011
2/22
/201
13/
15/2
011
4/5/
2011
4/26
/201
15/
17/2
011
Date
Fre
qu
ency
of
Co
nse
cuti
ve 3
0 m
inu
te i
nte
rval
s
Verbal Aggression Physical Aggression
4/ 26
T r az od4/ 21
S er oque
5/ 4
C l or az epam
6/ 8
S er oquel
6/ 22
S er oquel
12/ 14
C l oz a r i
12/ 30
C l oz a r
1/ 6
S er oquel
1/ 29
C l oz a r i l
3/ 10
S er oquel
3/ 15
K l onopi n
3/ 24
S er oquel
5/ 5
Ser oquel
10/ 26
R i s per da l
11/ 2
R i s per da l
5/ 26
P ax i l
7/ 1
K l onopi
8/ 4
K l onopi n
D C
9/ 23
D epakote
2/ 9
R i s per da l
3/ 3
R i s per da
3/ 17
R i s per da l
3/ 31
R i s per da l
4/ 14
R i s per da l
5/ 4
R i s per da l
11/ 3
D epakote
12/ 15
D epakote
1/ 6
D epakote
11/ 7
R i s per d
Orang e= DecreaseGreen= Increase/A dd
Resident 1 Cumulative Verbal/Physical Aggression
40
60
80
100
120
140
tiv
e 30
min
ute
In
terv
als
Subject 2Cumulative Verbal/Physical Aggression
5/4 6/86/22 Seroquel
12/14Clozaril
12/30 Clozaril
1/6 SeroquelClozaril
1/29 Clozaril Seroquel
3/10 Seroquel
3/15Klonopin
3/24 Seroquel
5/5 Seroquel
10/26
11/2 Risperdal
5/26Paxil
7/1 Klonopin
8/4Klonopin
11/7 Risperdal
0
20
4/1/
2009
4/22
/200
9
5/13
/200
9
6/2/
2009
6/23
/200
9
7/14
/200
9
8/4/
2009
8/25
/200
9
9/15
/200
9
10/6
/200
9
10/2
7/20
09
11/1
7/20
09
12/8
/200
9
12/2
9/20
09
1/19
/201
0
2/9/
2010
3/2/
2010
3/23
/201
0
4/13
/201
0
5/4/
2010
5/25
/201
0
6/15
/201
0
7/6/
2010
7/27
/201
0
8/17
/201
0
9/7/
2010
Co
nse
cu
Date
Verbal Aggression Physical Aggression
4/26DC Trazodone
4/21Seroquel
5/4 Clorazepam
6/8 Seroquel
q 10/26 Risperdal
From Kupfer, Eastridge, Buzan, & Castro, 2012
From Kupfer, Eastridge, Buzan, & Castro, 2012
SUMMARY OF MEDICATIONS
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